It's not exactly a buyer's market for people who purchase their own health insurance. Prices can be high and options severely limited. A key piece of the Affordable Care Act is supposed to change that. New health exchanges will allow people to comparison shop for insurance, maybe even get a subsidy to help pay for it.

But as New Hampshire Public Radio's Todd Bookman reports, some people may still be left with few choices.

JON LYNCH: If I was like a healthy 26-year-old who, you know, thinks they're invincible or whatever, it's fine, but, like, I'm not in that position. I need to get medication because I have, like, a long-term condition.

BOOKMAN: That condition is asthma. Lynch, who also just finished a degree in English at the University of New Hampshire, uses both an emergency inhaler and a daily medicine. He can't afford the prescriptions and is biding his time until October. That's when the new exchanges go live, and the tax subsidies meant to make coverage affordable become available. The mandate that all Americans have insurance kicks in January 1st.

LYNCH: And so, for better or for worse, I'm tied up with the exchange. I'm at the mercy of the exchange.

BOOKMAN: So are an estimated seven million other individuals and small business employers expected to take part in exchanges nationwide. There's been concern that in some markets, they won't have many options to choose from. The Obama administration is trying to put that talk to rest. In a memo, it said more than 120 companies have applied to sell plans, and nearly 90 percent of shoppers will have more than five insurance companies to choose between. The picture, though, looks very different in some states.

Rhode Island, three insurers are participating. Vermont, just two. And in New Hampshire, the concern is that Granite Staters will have just one company to buy from.

LINDA BLUMBERG: Listen, when you have states that have very limited numbers of carriers dominating the market, this is not a significant change.

BOOKMAN: Linda Blumberg is a senior fellow at The Urban Institute. She says many states are like New Hampshire, where one company, Anthem Blue Cross, sells more than 80 percent of the plans. When the exchange opens, they could get all that business, too: in effect, a monopoly. But Lisa Guertin, president of Anthem, claims that even if other insurers did enter the market, that alone wouldn't push premiums down.

LISA GUERTIN: The price of health insurance on or off the exchange is a direct reflection of the underlying cost of care.

BOOKMAN: Guertin says the cost of care isn't set by insurers. It's set by providers, by doctors and hospitals. The deputy commissioner at the New Hampshire Insurance Department agrees. Alex Feldvebel argues that because providers drive price, insurance company monopolies can actually be good things.

ALEX FELDVEBEL: The way it works out is that competition in the insurance market doesn't necessarily help the consumer in terms of lower prices for insurance.

BOOKMAN: The reason for this, according to Feldvebel, is that what you're buying with health insurance isn't just access to health care. What you're getting is a negotiator. Companies like Anthem can walk into contract talks with more leverage. They say to a hospital: We can bring you this many bodies if you give us a good deal on their care.

FELDVEBEL: And what does the insurance carrier need to get a good discount? It needs to be big and have a lot of covered lives.

BOOKMAN: So if big insurance companies get even bigger by cleaning up in the exchange, Feldvebel believes that prices could actually go down. But he still says that in the long run, more competition will be better for consumers - people like 26-year-old Jon Lynch. When he goes to shop in October, he wants choices.

LYNCH: And so if the exchange doesn't do anything to foster that, what's the point?

BOOKMAN: And while skeptics of the health overhaul law will likely be asking that same question, for people with no insurance or who have been denied due to pre-existing conditions, they may be willing to trade less competition for more coverage. For NPR News, I'm Todd Bookman in Concord, New Hampshire. Transcript provided by NPR, Copyright NPR.